艾滋病在非洲的发展援助与成人死亡率。

HIV development assistance and adult mortality in Africa.

机构信息

Division of General Medical Disciplines, Center for Health Policy, Stanford University, Stanford, California 94305, USA.

出版信息

JAMA. 2012 May 16;307(19):2060-7. doi: 10.1001/jama.2012.2001.

DOI:10.1001/jama.2012.2001

PMID:22665105

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC3434229/

Abstract

CONTEXT

The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the US President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries. The initiative's effect on all-cause adult mortality is unknown.

OBJECTIVE

To determine whether PEPFAR was associated with relative changes in adult mortality in the countries and districts where it operated most intensively.

DESIGN, SETTING, AND PARTICIPANTS: Using person-level data from the Demographic and Health Surveys, we conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1000 adults between 15 and 59 years old) and PEPFAR's activities. Across countries, we compared adult mortality in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with 18 African nonfocus countries from 1998 to 2008. We performed subnational analyses using information on PEPFAR's programmatic intensity in Tanzania and Rwanda. We employed difference-in-difference analyses with fixed effects for countries and years as well as personal and time-varying area characteristics.

MAIN OUTCOME MEASURE

Adult all-cause mortality.

RESULTS

We analyzed information on 1 538 612 adults, including 60 303 deaths, from 41 surveys in 27 countries, 9 of them focus countries. In 2003, age-adjusted adult mortality was 8.3 per 1000 adults in the focus countries (95% CI, 8.0-8.6) and 8.5 per 1000 adults (95% CI, 8.3-8.7) in the nonfocus countries. In 2008, mortality was 4.1 per 1000 (95% CI, 3.6-4.6) in the focus countries and 6.9 per 1000 (95% CI, 6.3-7.5) in the nonfocus countries. The adjusted odds ratio of mortality among adults living in focus countries compared with nonfocus countries between 2004 and 2008 was 0.84 (95% CI, 0.72-0.99; P = .03). Within Tanzania and Rwanda, the adjusted odds ratio of mortality for adults living in districts where PEPFAR operated more intensively was 0.83 (95% CI, 0.72-0.97; P = .02) and 0.75 (95% CI, 0.56-0.99; P = .04), respectively, compared with districts where it operated less intensively.

CONCLUSIONS

Between 2004 and 2008, all-cause adult mortality declined more in PEPFAR focus countries relative to nonfocus countries. It was not possible to determine whether PEPFAR was associated with mortality effects separate from reductions in HIV-specific deaths.

摘要

背景

全球卫生倡议对人口健康的影响尚不确定。2003 年至 2008 年期间，美国总统艾滋病救援计划（PEPFAR）作为有史以来针对单一疾病开展的最大规模的倡议，在 12 个非洲重点国家密集开展工作。该倡议对全因成人死亡率的影响尚不清楚。

目的

确定 PEPFAR 是否与在其密集开展工作的国家和地区的成人死亡率的相对变化有关。

设计、地点和参与者：我们使用来自人口与健康调查的个人层面数据，对成人死亡率（15 至 59 岁成年人中每年每 1000 人死亡的概率）和 PEPFAR 的活动进行了国家间和国家内分析。在国家间，我们比较了 1998 年至 2008 年间 9 个非洲重点国家（埃塞俄比亚、肯尼亚、莫桑比克、纳米比亚、尼日利亚、卢旺达、坦桑尼亚、乌干达和赞比亚）与 18 个非洲非重点国家的成人死亡率。我们使用有关 PEPFAR 在坦桑尼亚和卢旺达计划开展强度的信息进行了次国家级分析。我们使用了国家和年份的固定效应以及个人和随时间变化的地区特征的差异-差异分析。

主要结局指标

成人全因死亡率。

结果

我们分析了来自 27 个国家的 41 项调查中的 1 538 612 名成年人的信息，包括 60 303 例死亡，其中 9 个国家为重点国家。2003 年，重点国家的成人死亡率经年龄调整后为每 1000 名成年人 8.3 例（95%CI，8.0-8.6），而非重点国家为每 1000 名成年人 8.5 例（95%CI，8.3-8.7）。2008 年，重点国家的死亡率为每 1000 人 4.1 例（95%CI，3.6-4.6），而非重点国家为每 1000 人 6.9 例（95%CI，6.3-7.5）。2004 年至 2008 年间，与非重点国家相比，生活在重点国家的成年人的死亡率调整后的比值比为 0.84（95%CI，0.72-0.99；P=0.03）。在坦桑尼亚和卢旺达，PEPFAR 密集开展工作的地区与开展工作较少的地区相比，生活在前者的成年人的死亡率调整后的比值比分别为 0.83（95%CI，0.72-0.97；P=0.02）和 0.75（95%CI，0.56-0.99；P=0.04）。